Hi there,
I got a denial from Anthem here. I'm pretty sure this will just have to be appealed but wanted to be sure. Codes billed:
93620.26
93621.26
93286.26.59 x2
33233
33249
93641.26
Basically we have an EP study followed by upgrade of a dual pacemaker to a dual ICD. Anthem paid for all codes except the 93621.26 and 93641.26 saying it seems another procedure describes the services rendered. (Mapped to: N22-N22 - PX DESCRIBES SVCS RENDERED)
I think it's coded correctly and that there's not another code to describe these 2 services. One thing is being done in conjuction with the EP portion of procedure and the other was done with the ICD implant portion...
DESCRIPTION OF PROCEDURE: The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and he provided informed written consent. The patient was brought to the electrophysiology laboratory where he was prepped and draped in the usual sterile fashion. His pacemaker was interrogated and reprogrammed to DDI 40 mode for the EP study.
Lidocaine 2% was used to anesthetize the right inguinal region. Using an introducer needle, the right femoral vein was accessed 3 times and 3 wires were placed under fluoroscopic guidance. A locking 8 and 2 other 8-French sheaths were placed.
A decapolar CS catheter was then advanced to the coronary sinus under fluoroscopic guidance. It was secured and used for left atrial pacing and recording for the EP study. Deflectable quads were likewise advanced to the RV apical and His positions. Once catheters and sheaths were in place, the patient was administered IV Heparin for DVT prophylaxis.
His presenting rhythm was sinus bradycardia with a basic cycle length of 960 milliseconds. The PR interval was 255 with a QRS duration of 115 and a QT of 440. The AH interval was 120 milliseconds with an HV of 55 milliseconds.
Ventricular pacing was performed. The VA Wenckebach cycle length was greater than 800 milliseconds. The AV Wenckebach cycle length was 660 milliseconds. There was evidence for an A2-H2 jump, but no echo beats were seen. The AV nodal ERP of 800/550.
Ventricular stimulation was then performed. Single, double, and triple extrastimuli were delivered from the RV apex. We proceeded with a drive train cycle length of 600 milliseconds followed by 400 milliseconds, with no sustained inducible arrhythmias.
The His catheter was then moved to the RV outflow tract and the stimulation was repeated. With triple ventricular extrastimuli, the patient was inducible for a monomorphic VT. It was very rapid with a cycle length of 200 milliseconds. This was a left bundle, left inferior axis with a late R-wave transition. This quickly degenerated into ventricular fibrillation, and the patient was rescued with a 200 joule shock.
Given his history of syncope and wide complex arrhythmias, we then proceeded to upgrade his pacemaker to a defibrillator. The catheters and sheaths were removed and hemostasis achieved with manual pressure. The patient was then fully reprepped and draped for the ICD procedure. Left upper extremity venography confirmed a patent left subclavian system around the existing pacing wires.
Lidocaine 2% was used to anesthetize the left pectoral region. An incision was made over the prior implantation site. Using blunt dissection and brief bursts of electrocautery, the device pocket was opened and the device and leads were freed from their adhesions. Using the appropriate torque wrench, the pacemaker pulse generator was removed from the field. The RA lead was tested and found to have stable parameters.
Left subclavian venous access was then obtained with an introducer needle using the venogram as a guide. A wire was placed. We were unable to advance the J-wire, but a Wholey wire was able to traverse the SVC. There was binding noted at the existing pacing leads. We attempted to advance the lead through a 9-French sheath, but were held up at the SVC. The sheath was then exchanged for a long 9-French but was unable to traverse around the bend. We then used a 7-French dilator and we were able to get through. Following this, the 9-French long sheath was then able to be advanced around the bend into the SVC. The RV lead was then delivered to the RV apical septum under fluoroscopic guidance. There was adequate safety margin between the existing pacing lead and the ICD lead. The sheath was then split and removed. The lead was secured to the underlying tissue with 0 silk x2.
Hemostasis was ensured in the pocket with further electrocautery. The pocket was irrigated with copious Bacitracin and saline solution. The ICD pulse generator was connected to the leads with the appropriate torque wrench. A cap was placed on the existing RV lead and secured with 0 silk x2. The device and lead assembly were then replaced in the cleaned pocket. The pulse generator was secured to the underlying tissue with 0 silk x1. The pocket was closed with a 2-0 layer.
The patient was then fully sedated for DFT testing. Shock on T induced VF, which was successfully detected with minimal dropout. A single 25 joule shock was successful in restoring sinus rhythm. The patient's DFT is therefore less than or equal to 25 joules.
The pocket was then fully closed with 3-0 and 4-0 layers. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.
The patient tolerated procedure well, and was transferred to a monitored bed in stable condition.
Jessica CPC, CCC
I got a denial from Anthem here. I'm pretty sure this will just have to be appealed but wanted to be sure. Codes billed:
93620.26
93621.26
93286.26.59 x2
33233
33249
93641.26
Basically we have an EP study followed by upgrade of a dual pacemaker to a dual ICD. Anthem paid for all codes except the 93621.26 and 93641.26 saying it seems another procedure describes the services rendered. (Mapped to: N22-N22 - PX DESCRIBES SVCS RENDERED)
I think it's coded correctly and that there's not another code to describe these 2 services. One thing is being done in conjuction with the EP portion of procedure and the other was done with the ICD implant portion...
DESCRIPTION OF PROCEDURE: The indications, risks, benefits, alternatives, and details of the procedure were discussed with the patient, and he provided informed written consent. The patient was brought to the electrophysiology laboratory where he was prepped and draped in the usual sterile fashion. His pacemaker was interrogated and reprogrammed to DDI 40 mode for the EP study.
Lidocaine 2% was used to anesthetize the right inguinal region. Using an introducer needle, the right femoral vein was accessed 3 times and 3 wires were placed under fluoroscopic guidance. A locking 8 and 2 other 8-French sheaths were placed.
A decapolar CS catheter was then advanced to the coronary sinus under fluoroscopic guidance. It was secured and used for left atrial pacing and recording for the EP study. Deflectable quads were likewise advanced to the RV apical and His positions. Once catheters and sheaths were in place, the patient was administered IV Heparin for DVT prophylaxis.
His presenting rhythm was sinus bradycardia with a basic cycle length of 960 milliseconds. The PR interval was 255 with a QRS duration of 115 and a QT of 440. The AH interval was 120 milliseconds with an HV of 55 milliseconds.
Ventricular pacing was performed. The VA Wenckebach cycle length was greater than 800 milliseconds. The AV Wenckebach cycle length was 660 milliseconds. There was evidence for an A2-H2 jump, but no echo beats were seen. The AV nodal ERP of 800/550.
Ventricular stimulation was then performed. Single, double, and triple extrastimuli were delivered from the RV apex. We proceeded with a drive train cycle length of 600 milliseconds followed by 400 milliseconds, with no sustained inducible arrhythmias.
The His catheter was then moved to the RV outflow tract and the stimulation was repeated. With triple ventricular extrastimuli, the patient was inducible for a monomorphic VT. It was very rapid with a cycle length of 200 milliseconds. This was a left bundle, left inferior axis with a late R-wave transition. This quickly degenerated into ventricular fibrillation, and the patient was rescued with a 200 joule shock.
Given his history of syncope and wide complex arrhythmias, we then proceeded to upgrade his pacemaker to a defibrillator. The catheters and sheaths were removed and hemostasis achieved with manual pressure. The patient was then fully reprepped and draped for the ICD procedure. Left upper extremity venography confirmed a patent left subclavian system around the existing pacing wires.
Lidocaine 2% was used to anesthetize the left pectoral region. An incision was made over the prior implantation site. Using blunt dissection and brief bursts of electrocautery, the device pocket was opened and the device and leads were freed from their adhesions. Using the appropriate torque wrench, the pacemaker pulse generator was removed from the field. The RA lead was tested and found to have stable parameters.
Left subclavian venous access was then obtained with an introducer needle using the venogram as a guide. A wire was placed. We were unable to advance the J-wire, but a Wholey wire was able to traverse the SVC. There was binding noted at the existing pacing leads. We attempted to advance the lead through a 9-French sheath, but were held up at the SVC. The sheath was then exchanged for a long 9-French but was unable to traverse around the bend. We then used a 7-French dilator and we were able to get through. Following this, the 9-French long sheath was then able to be advanced around the bend into the SVC. The RV lead was then delivered to the RV apical septum under fluoroscopic guidance. There was adequate safety margin between the existing pacing lead and the ICD lead. The sheath was then split and removed. The lead was secured to the underlying tissue with 0 silk x2.
Hemostasis was ensured in the pocket with further electrocautery. The pocket was irrigated with copious Bacitracin and saline solution. The ICD pulse generator was connected to the leads with the appropriate torque wrench. A cap was placed on the existing RV lead and secured with 0 silk x2. The device and lead assembly were then replaced in the cleaned pocket. The pulse generator was secured to the underlying tissue with 0 silk x1. The pocket was closed with a 2-0 layer.
The patient was then fully sedated for DFT testing. Shock on T induced VF, which was successfully detected with minimal dropout. A single 25 joule shock was successful in restoring sinus rhythm. The patient's DFT is therefore less than or equal to 25 joules.
The pocket was then fully closed with 3-0 and 4-0 layers. Steri-Strips and a Tegaderm dressing as well as a pressure dressing were applied.
The patient tolerated procedure well, and was transferred to a monitored bed in stable condition.
Jessica CPC, CCC